Healthcare Provider Details

I. General information

NPI: 1396712477
Provider Name (Legal Business Name): BREAKWATER ADULT FAMILY CARE HOME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22699 SW BREAKWATER BLVD
DUNNELLON FL
34431-4039
US

IV. Provider business mailing address

22699 SW BREAKWATER BLVD
DUNNELLON FL
34431-4039
US

V. Phone/Fax

Practice location:
  • Phone: 352-465-4877
  • Fax: 352-465-8033
Mailing address:
  • Phone: 352-465-4877
  • Fax: 352-465-8033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number6905655
License Number StateFL

VIII. Authorized Official

Name: MR. VINCE L JACOBS
Title or Position: OWNER-PROVIDER
Credential:
Phone: 352-465-4877